Empire Plan Rx copays change Oct. 1
If you are
enrolled in the state’s Empire Plan, your copay for
generic drugs will be $5 starting October 1, and your
copay for brand-name drugs will be $15.
The $15 copay will apply even if no generic equivalent is
available.
If your doctor feels there is a medically necessary
reason why you or your family member must have a
brand-name drug when a generic equivalent is available,
you can appeal the mandatory generic requirement.
Call Express Scripts at 1-800-964-1888 for an appeal form
which you and your doctor must complete.
If the appeal is granted, you will be charged the $15
brand-name-drug copayment, but you will not have to pay
the difference between the costs of the generic and
brand-name drugs.
Enrollees who use maintenance drugs for a chronic
condition, such as high blood pressure or asthma, need
only make a single copayment for a 90-day supply of any
prescription, if the doctor writes the prescription for
90 days.
This applies to certain controlled substances such as
Ritalin for attention deficit disorder.
Maintenance prescriptions may be filled at any
participating community pharmacy or through the Empire
Plan mail-order program, which can be reached by calling
Express Scripts at 1-800-964-1888.
— Deborah Stayman
| Benefit Enrollment-all plans |
Description of change |
| Dependent student coverage | Continues for 3 months following completion of coursework; not retroactive |
| Waiting period for new enrollees | 56 days for all benefits |
| Empire Plan | |
| Adult immunizations | Coverage added for influenza, pneumonia, measles, mumps, rubella, chicken pox & tetanus |
| Centers of Excellence for Infertility | Voluntary program for infertility treatment at specialized centers; lifetime maximum $25,000/individual; coverage extended to either partner; transportation & lodging costs included |
| Centers of Excellence for Transplants | Voluntary program for organ & tissue transplants at specialized centers; transportation & lodging costs included |
| Disease management program | Voluntary program to provide information & coordinate treatment for high-cost chronic illnesses |
| Hearing aids | Increase to $800 retroactive to 1/1/00 |
| Newborn routine exam by non-par provider | $150 for post-birth exam not subject to deductible or coinsurance |
| Nurse Call hotline | Toll-free line with nurse available 24 hours/7 days to answer clinical & benefit questions |
| Pediatric immunizations | Influenza vaccine added |
| Physical therapy copay (hospital-based) | Same copay as office-based physical therapy ($8 currently) |
| Pre-admission testing copay | $25 copay for tests before hospital admission to be waived |
| Prescription drug copay | $5 copay for generics/$15 copay for brand name drugs, applies even if no generic equivalent is available |
| Routine physical exams by non-par provider | For employees & spouses age 50+ annual $250 allowance |
| Skilled nursing facility admissions | Precertification required for all admissions |
| Dental & Vision | |
| Dental benefits | Sealants for dependents under 14 & general anesthesia in dentist’s office added |
| Vision benefits | Dependents under 19 & adults with vision loss due to medical condition can receive annual benefits; enrollees can purchase these at a discount from par providers: premier frames, plastic photosensitive lenses, reflection free coating, progressive addition lenses, blended invisible bifocals, polycarbonate lenses for adults, polaroid & high index lenses, scratch protective coating |
If you have questions, please contact the health benefits administrator in your agency personnel office or PEF Health Benefits at 1-800-342-4306 or 518-785-1900, ext. 283. Or emailto:dstayman@pef.org